Transcript Pulmonary PPT

Pulmonary
RT 210 A&P
Unit A
Upper airway
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Nose
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Warms, humidifies and filters gas
External opening-nares
Conchae-nares to nasal pharynx
Nasal conchae-turbinates, allows maximum
air surface contact
Posterior nose is ciliated pseudostratified
columnar epithelium whose purpose is to
filter, humidify and warm
Upper airway
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Mouth – oral cavity
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Lined with stratified squamous
Upper airway
Pharynx
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Extends from base of skull to esophagus (about 5
inches)
The nasal cavities and mouth to the point where
the airway and digestive tract separate
Three parts
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Nasopharynx (behind the nose)
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Aconchae to uvula
Lined with pseudostratified ciliated columnar epithelium
Purpose: gas conduction to airways, filters and houses
adenoids (defense)
Upper airway
Pharynx
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Three parts (con’t)
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Oropharynx (behind the mouth)
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Uvula to epiglottis
Function: defense, holds tonsils, gas conduction, food
conduction, filtration
Stratified squamous epithelium
Upper airway
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Pharynx
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Three parts (con’t)
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Laryngopharynx (below the hyoid bone behind
the larynx)
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Lined with stratified squamous epithelium
Function: gas and food conduction
Larynx divides upper and lower airway at the vocal
cords
Opening to larynx at the glottis
Lower Airway
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Larynx
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Functions:
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Conduct gas
Protect lower airway
Cough
Speech
Extends from c-3 to c-6
Lower Airway
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Larynx (cont)
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Unpaired cartilage
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Epiglottis covers the superior larynx opening on
swallowing, preventing food from entering
trachea
Thyroid - adam’s apple
Cricoid - only complete ring of cartilage
Lower Airway
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Larynx (cont)
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Paired cartilage
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Arytenoid - allows vocal cord movement
Corniculate-supports walls of the larynx
Cuneiform-connect epiglottis to the arytenoid
cartilage
Tracheobronchial Tree
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Functions for air conduction
Pseudostratified ciliated columnar epithelium
Layers (change further down T.B. tree):
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Cartilaginous layer
Lamina propria - contains vessels and nerves
epithelium
Tracheobronchial Tree
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Trachea (generation 0)
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Approximately 4.5 - 5.5 inches in length, or 1012 cm
Approximately 1 inch in diameter, or 2-2.5 cm
16-20 c-shaped cartilage rings prevent collapse
Anterior to esophagus
Ciliated pseudostratified columnar epithelium
Divides at carina into 2 mainstem bronchus
Tracheobronchial Tree
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Mainstem Bronchus (generation 1)
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Right
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20-30 degree angle – less acute angle
Shorter and wider than left
Left
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40-60 degree angle – more acute angle
Smaller and longer than right
Structurally similar to trachea
Tracheobronchial Tree
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Lobar bronchi (generation 2)
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Right mainstem divides into 3 lobar divisions
(accommodates 3 lobes)
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Upper
Middle
Lower
Left mainstem divides into 2 lobar (2 lobes)
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Upper
Lower
Tracheobronchial Tree
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Segmental Bronchi (generation 3) are
named to the segments they represent
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Right upper lobe
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Apical
Posterior
Anterior
Right middle lobe
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Lateral
Medial
Tracheobronchial Tree
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Segmental Bronchi (generation 3) are named to
the segments they represent
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Right lower lobe
 Superior
 Medial basal
 Anterior basal
 Lateral basal
 Posterior basal
Tracheobronchial Tree
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Segmental Bronchi (generation 3) are named
to the segments they represent
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Left upper lobe
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Apical-posterior* (upper division)
Anterior (upper div.)
Superior lingula (lower div.)
Inferior lingula (lower division)
Left lower lobe
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Superior
Anteromedial*(antero basal)
Lateral basal
Posterior basal
*Some authors feel that the left lung should be numbered so that there
are eight segments, the apical-posterior is numbered 1 and
anteromedial is numbered 6
Tracheobronchial Tree
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Subsegmental bronchi (generation #4-9)
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Diameter from 1-4 mm
Tubes greater than 1 mm with connective tissue
are bronchi
Bronchioles (generation # 10-15)
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Less than 1 mm
No connective tissue
Decreasing number of goblet cell/cilia
Ciliated cuboidal epithelium
Tracheobronchial Tree
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Terminal bronchioles (generation# 16)
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About 0.5mm in diameter
Cuboidal epithelium to squamous epithelium
Clara cells may secrete mucous/surfactant
End of conducting airways
Canals of Lambert
Parenchyma of the Lung
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Purpose
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Gas exchange between alveolar air/blood
called external respiration
Start at the respiratory bronchioles
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Generation #17-19
Gas exchange is beginning to occur
Some cuboidal but mostly squamous
Alveolar Ducts (generation #20-22)
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Alveoli separated by septal walls
Alveolar Sacs (generation #23)
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Clusters of 15-20 alveoli
Walls are other alveoli
Alveoli
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Air spaces that contain capillary walls
Approximately 300-600 million total
Simple squamous epithelium
Alveolar communication – pores of Kohn
(collateral ventilation)
Three types of alveolar cells
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Type I
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Type II (Clara Cells)
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Squamous epithelium – thin and flat
95% of alveolar cells
Allows gas diffusion
High metabolic rate
Produce surfactant
Type III
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Pneumocystic macrophages
Ingest and eliminates foreign bodies
The Lung
Location
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In thorax
Surrounds heart in mediastinum
Superior to the diaphragm
Surrounded by pleura in the thorax
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Parietal pleura - on the thorax
Visceral pleura - on the lung
Small potential space between the two filled
with small amount of serous fluid which
decreases friction
Structure
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Upper lung
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Apices – apex
Extends 1-2 inches above clavicle
Root or hilum is attachment of mainstem
bronchus and arteries
Base
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Shape is concave due to diaphragm
Right side is higher than the left due to the liver
Structure
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Bony thorax
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Surrounds and protects the lung
Aids in ventilation
Sternum
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18 cm long
Parts
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Manubrium - superior portion
Body or Gladiolus - middle portion
Xiphoid process – inferior portion
Notch above is the suprasternal notch
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Trachea is palpable behind it
Structure
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Sternum (cont)
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Junction of manubrium and body is the Angle of
Louis
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The point of tracheal bifurcation (carina)
True ribs
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Pairs 1-7
Connect directly to the sternum
False ribs
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Pairs 8-10
Connect to the sternum indirectly via the costal
cartilage
Structure
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Sternum (cont)
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Floating ribs
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Pairs 11 and 12
No attachment to sternum or other ribs
May also be called false ribs
Structure
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Mediastinum
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Heart
Great vessels
Trachea
Esophagus
Thymus gland
Lymphatic structures
Nerves
Thymus
Mucus Production and Movement
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Goblet Cells
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Submucosal Glands
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In the surface of the tracheobronchial tree
Secrete mucus
Below the lamina propria
Secrete mucus & bronchial secretions
Mucus Composition
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95% water
2% glyco protein
1 % carbohydrate
Mucus Production and Movement
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Mucus Composition (cont)
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Traces of lipid, debris, DNA, and foreign bodies
100 – 150 ml produced daily
Traps foreign bodies
Mucus Blanket
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Continuous blanket of mucus over the tracheobronchial
tree
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Layers
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Sol layer
* Near the tissue
* Is more liquid
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Gel layer
* Near air
* Is more thick
Mucus Production and Movement
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Layers (cont)
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Cilia
* Hair-like projections
* Extend into the sol layer
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Mucociliary escalator
* Formed by mucus blanket and cilia
* Cilia move in a wave like fashion
* Moves mucus upward at 2cm per minute
toward the mouth
* Means to remove the mucus from the lung
Mucus Production and Movement
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Sputum
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Mucus, saliva and nasal secretions
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Mobilized and expelled by cough
Alveolar Fluid
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Surfactant
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Detergent-like phospholipid
Decreases surface tension
Prevents alveolar collapse
Continuously produced, secreted, and eliminated
Muscles of Ventilation
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Diaphragm
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Separates thorax and abdomen
Muscular hemi-diaphragms
Normally dome-shaped
Right side higher than left due to liver
Flatten on inspiration
Phrenic nerve stimulates
Major muscle of ventilation
Normal diaphragmatic excursion is 1.5cm during
quiet breathing
May increase to 6-10cm during labored
ventilation
Muscles of Ventilation
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Intercostal Muscles
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Between ribs
2 layers
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Internal - helps with exhalation
External - helps with inhalation
T- 1 to T- 11 innervation
External-contraction pulls ribs up and out
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Increases anterior-posterior chest diameter for
inspiration
Internal-contraction pulls ribs down and in for
forced expiration
Muscles of Ventilation
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Accessory Muscles
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Elevate and stabilize chest for labored breathing
Neck and shoulder muscles
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Scalene
Sternocleidomastoid
Trapezium
Pectoralis
Muscles of Ventilation
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Expiratory Muscles
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Normally passive
Muscles of forced exhalation
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External oblique
Rectus abdominus
Internal oblique
Transverse abdominus
Types of Breathing
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Eupnea
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Normal breathing
12-20 breaths per minute
Hyperventilation: Rapid and/or deep
breathing
Hypoventilation: Slow and/or shallow
breathing
Dyspnea: Labored or difficult breathing
Apnea: No breathing occurs
Types of Breathing
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Biot’s Breathing
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Several short breaths followed by long, irregular
periods of apnea
Caused by brain damage and increased ICP
Cheyne-Stokes Breathing
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Increasing and decreasing depth and rate of
respirations followed by periods of apnea
Caused by CHF, decreased blood flow to
respiratory center, and brain damage
Types of Breathing
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Kussmaul Breathing
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Deep gasping type of respiration
Caused by diabetic acidosis
Tachypnea: Respiratory rate >20 bpm
Bradypnea: Respiratory rate < 12
Regulation of Breathing
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Medullary Respiratory Center
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Medulla is lowest part of brain stem
Contains widely dispersed respiratory neurons
Dorsal Respiratory Groups
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Mainly inspiratory neurons
Send impulses to diaphragm and external intercostals
muscles
Regulation of Breathing
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Ventral Respiratory Groups
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Inspiratory neurons
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Abduct vocal cords
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Increase diameter of glottis
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Innervate diaphragm and external intercostals
Expiratory neurons
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Send impulses to internal intercostals and
abdominal expiratory muscles
Regulation of Breathing
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Pontine Respiratory Centers
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Pons is located above the medulla on the brain
stem
Apneustic center
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Sends signals to promote a prolonged, unrestrained
inspiration
Vagal and pneumotaxic center impulses hold the
stimulatory effect in check
Pneumotaxic center
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Controls inspiratory time
Strong signals increase respiratory rate
Weak signals prolong inspiration and increase tidal
volumes
Reflex Control of Breathing
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Hering-Breuer Inflation Reflex
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Stretch receptors located in smooth muscle of
large and small airways
When stimulated they send a signal via vagus
nerve to the medullary center to stop further
inspiration
In adults it is activated at a tidal volume of about
800 to 1000 ml
Cough
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One of the most common symptoms
associated with lung disease
Powerful protective mechanism for the lung
and airways
Caused by mechanical, chemical,
inflammatory, or thermal stimulation of the
cough receptors
Made up of three phases
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Inspiratory phase
Compression phase
Expulsion phase
Cough
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Causes and Clinical Presentation
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Acute cough most often associated with viral
infection of the upper airway
Chronic cough often associated with postnasal
drip, asthma, COPD, gastroesophageal reflux,
and left ventricular failure
Cough
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Descriptions
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The type of cough present should be
documented using commonly accepted
adjectives.
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Productive—mucus is produced with the cough
Effective—a strong cough
Weak—ineffective
Dry—no secretions present
Chronic productive—patient produces phlegm most
days for at least 3 weeks
Sputum Production
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Sputum is the mucus expelled from the
tracheobronchial tree that has been
contaminated by the mouth.
Phlegm is the term used to describe mucus
strictly from the tracheobronchial tree.
Sputum Production
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Causes and Descriptions
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Caused by inflammation of the mucus secreting glands that
line the airways
Inflammation occurs with infection, cigarette smoke, and
allergies.
Sputum should be described as to the color, consistency,
quantity, time of day, odor, and presence of blood.
Thick but clear sputum is consistent with dehydration.
Pink frothy sputum is consistent with pulmonary edema.
Thick, purulent (pus-containing) sputum is consistent with
infection.
Hemoptysis
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Causes
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Persistent strong coughing
Acute infection
Bronchogenic carcinoma
Cardiovascular disease
Trauma
Anticoagulant therapy
Hemoptysis
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Descriptions
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Streaky hemoptysis refers to blood-tinged
sputum.
Massive hemoptysis refers to more than 400 ml
of blood in 3 hours or 600 ml in 24 hours. It is
consistent with trauma, lung cancer,
tuberculosis, and bronchiectasis. It also is more
common in patients on anticoagulant therapy
Hemoptysis
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Hemoptysis versus Hematemesis
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Determining if the blood is from the lung versus
the stomach is important.
Blood from the lung is often associated with
pulmonary symptoms.
Blood from the stomach is associated with GI
symptoms (see Table 3-4 CARC p. 33)
Shortness of Breath (Dyspnea)
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Dyspnea is a common symptom of patients
with lung or cardiac problems.
Subjectiveness of Dyspnea
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Dyspnea is a subjective complaint that varies
with pathologic and psychological variables.
The degree of dyspnea may not correlate with
objective measures of impairment.
Dyspnea should always be investigated even if
initial tests are normal.
Shortness of Breath (Dyspnea)
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Dyspnea Scoring System
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A variety of scoring systems have developed to
help quantify dyspnea at a single point in time to
help track changes with treatment.
The visual analog scales use a straight line 10 cm
long. The patient marks a dash on the line
consistent with the level of dyspnea currently
experienced.
The Modified Borg Scale uses a 0 to 10 scale.
Many other tools are also available. Each has its
own advantages and disadvantages.
Shortness of Breath (Dyspnea)
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Causes, Types, and Clinical Presentation of Dyspnea
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Dyspnea tends to occur when the patient experiences
increased WOB, increased drive to breathe, and/or
decreased ventilatory capacity.
The adjectives patients use to describe their dyspnea may
correlate with the underlying pathology. For example,
patients with CHF tend to feel the sensation of
“suffocation.” Asthmatics often describe dyspnea by saying
they have “tightness in their chest.”
Acute dyspnea is associated with acute illnesses such as
asthma, pneumonia, pneumothorax, etc.
Chronic dyspnea is almost always progressive. It is most
often seen in patients with COPD and CHF.
Shortness of Breath (Dyspnea)
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Descriptions
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Paroxysmal nocturnal dyspnea (PND) is often seen in CHF
patients. It is associated with the collection of fluid in the
lung during sleep.
Orthopnea is also associated with CHF.
Trepopnea (dyspnea while lying on one side) is less
common but is seen in patients with unilateral disorders.
Platypnea (dyspnea in the upright position) is not common
but implies a disorder is present that causes increased
shunting of blood from right to left when the upright
position is assumed.
Egan defines trepopnea & platypnea differently from above with both being in the upright
position, and platypnea being relieved by the patient lying down
Chest Pain
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Chest pain is the cardinal symptom of heart
disease.
Chest pain may be seen in patients with
lung disease when the pleural lining is
abnormal.
Classic chest pain associated with heart
disease is known as angina, and it signals a
medical emergency.
Chest Pain
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Pulmonary Causes of Chest Pain
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Pain associated with lung disease is most often
the result of pleural inflammation.
Pneumonia and pulmonary infarction may cause
pleural pain.
Descriptions
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Chest pain from heart disease is often described as
aching, squeezing, pressing, or viselike. It often
increases with exercise.
Patients with pleuritic chest pain may be leaning toward
one side and describe the pain as stabbing or burning.
They state the pain increases with deep breathing.
Dizziness and Fainting (Syncope)
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Syncope is a temporary loss of
consciousness due to reduced blood flow
and oxygen to the brain.
Syncope is caused by a large variety of
disorders from something as simple as
dehydration to serious cerebral thrombosis.
Patients with lung disease who cough very
forcefully may experience syncope.
Dizziness and Fainting (Syncope)
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Descriptions
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Some patients experience syncope when they
suddenly stand up. This is often associated with
orthostatic hypotension.
Cough syncope occurs with severe coughing and
is the result of reduced venous return due to
high intrathoracic pressures.
Swelling of the Ankles
(Dependent Edema)
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Patients with chronic hypoxemia often develop right
heart failure.
Right heart failure leads to reduced venous return
and increased hydrostatic pressure in the peripheral
venous blood vessels especially in the dependent
tissues (e.g., ankles).
Ankle edema thus can be a sign of chronic lung
disease.
Ankle edema may also simply be a sign of heart
disease not associated with lung disease
Swelling of the Ankles
(Dependent Edema)
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Descriptions
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Pitting edema is present when the edematous
tissue is pressed inward and it does not return to
its normal position immediately.
Fever, Chills, and Night Sweats
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Descriptions
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Sustained fever is a continuously elevated fever
that varies little during a 24-hour period.
Remittent fever is continuously elevated but has
larger variations and spikes in a 24-hour period.
Intermittent fever refers to spikes in body
temperature cycling with periods of normal or
subnormal temperatures.
Fever is a concern because it may signal
infection and it increases oxygen consumption.
Fever, Chills, and Night Sweats
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Fever with Pulmonary Disorders
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Pneumonia
Lung abscess
Tuberculosis
Empyema
A lack of fever does not rule out infection.
Headache, Altered Mental Status,
and Personality Changes
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Lung disease can lead to headache when chronic
hypoxemia or hypercarbia is present.
Sudden changes in personality are common in
patients with chronic lung disease and may be due
to hypoxia, medications, or psychologic issues.
RTs must be sensitive to personality changes
because they may be indicative of acute lung
problems in the patient with chronic lung disease
Snoring
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Incidence and Causes
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Snoring occurs in about 5% to 10% of children and 10%
to 30% of adults.
Snoring is caused by excessive narrowing of the upper
airway with breathing during sleep. The airway narrowing
increases with inspiration and lessens during exhalation.
Obesity is the most common cause of obstructive sleep
apnea.
Enlarged tonsils, a large tongue, a short thick neck, and
nasal obstruction may contribute to the upper airway
narrowing during sleep.
Alcohol and sleeping medications can also make snoring
worse
Snoring
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Clinical Presentation
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Patients with obstructive sleep apnea always
snore during sleep.
OSA patients will complain of excessive daytime
sleepiness because their sleep continuity is
abnormal.
OSA patients may also complain of poor
concentration skills, bedwetting, impotence, high
blood pressure, and other complaints